I think a very challenging bipolar I diagnosis for me is a patient who also has a personality disorder, a paranoid personality disorder, and also has psychotic symptoms. It’s very difficult to determine the border between bipolar I and schizoaffective. There is a difficulty in keeping a clear plan of action when people around you, colleagues around you, are saying “he’s not bipolar, it’s schizophrenia”. This can be quite difficult, as there may be a lot of pressure to change the diagnosis when you know there is a very, very definite mood component.
I would initially focus on their mood state, which is relatively easy for most psychiatrists unless there are a lot of physical symptoms or there’s an extreme poverty of affect. That is slightly more difficult because you really have to try to highlight to them the negative impact of their behaviour and it is affecting their family and their work. With many patients there’s a discordance. It’s almost as if they’re on a motorway and the brakes have failed but they can’t stop the car. There are a lot of patients we’d describe that way. It is quite difficult.
I think in general it’s very important that patients feel that they’re taking an active part in the treatment, in deciding the treatment and ensuring they know why they’re taking it. That then ensures long-term compliance and that’s what we want in bipolar disorder.
There’s always the exception. There are obviously some personalities who prefer that their psychiatrist be in control. But in general I prefer that the patients feel they have an active part in treatment because it’s their illness. They have to know how it works in order to stay better - treatment is not just medication, there’s psychosocial interventions that work in conjunction with it.